Adult Information Gathering Form

Please enable JavaScript in your browser to complete this form.

Demographic Information

Date *

Name *

First

Last

DOB *

Age *

Gender *

• Male
• Female

Birth Place *

Preferred Pronouns *

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone Number(s): *

Is it ok to leave a voicemail? *

• Yes
• No

Email *

Would you like to receive email communication? *

• Yes
• No

Is it ok to send something in the mail? *

• Yes
• No

How were you introduced to us? *

If you found us online what words did you search to find us? *

* Please complete below for additional client

Name

First

Last

DOB

Age

Gender

• Male
• Female

Birth Place

Preferred Pronouns

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone Number(s):

Is it ok to leave a voicemail?

• Yes
• No

Email

Would you like to receive email communication?

• Yes
• No

Is it ok to send something in the mail?

• Yes
• No

How Have We Come to Meet?

What are the 3 biggest concerns you have right now? How long have each been going on? Put them in order of importance: *

What do you think those that care about you would say their concern(s) is/are in regards to you? *

What solutions (helpful or unhelpful) have you tried to resolve the above concerns? *

Have you had therapy in the past? If so, with whom and when? What reasons did you attend therapy for? Please share with us about your experience. What was helpful? Unhelpful? *

Change is Coming...

What are your expectations from therapy? *

Looking into the future, how will you know that our work and time together has been worth it? List concrete changes you will see: *

What other things would you like to see change in your life (family, career, health, relationships, etc.)? *

Do you foresee any obstacles to achieving your goals or the desired changes? *

How long do you think therapy will need to last to achieve your goals? Write down a target date: *

List 5 strengths about yourself or that others say about you, give examples of each: *

Is there anyone that you would like to be a part of your sessions or think may be helpful to be part of sessions either now or in the future? *

Medical & Wellness Information

What do you do for wellness (i.e. healthy food choices, exercise, limits on TV/electronics/work, managing stress, family time, leisure, etc.)? Give examples of each: *

How do you achieve balance in your life? *

Have you ever received psychiatric services before? *

• Yes
• No

If yes, how long ago, with whom, for what, medications prescribed and results:

Do you have any allergies (food, environmental, medicinal, animal, etc.) *

Do you have any current or past medical issues, hospitalizations, accidents, injuries or surgeries? If yes, what? *

Is there a family history of the above medical issues/concerns? *

Are you presently under a physician’s/psychiatrists care? If so, for what reason? *

Is there anyone in your life that is currently dealing with a medical issue that you are concerned about? If so, whom, for what? *

In the past year, have there been any changes in your life? (i.e.: moves, appetite, sleep, health, family, overall functioning)? *

List any medications (over-the -counter & prescribed), nutritional or herbal supplements, or alternative treatments (acupuncture, chiropractic, etc.) you are taking/doing and the reasons: *

Important Questions We Must Ask

Have you ever had suicidal ideations? *

• Yes
• No

If yes, please explain:

Have you ever planned to hurt yourself? *

• Yes
• No

If yes, please explain:

Have you ever attempted to hurt yourself? *

• Yes
• No

If yes, please explain:

Have you ever felt like you wanted to seriously hurt or harm someone else? *

• Yes
• No

If yes, please explain:

Do you have weapons in your home or access to weapons? *

• Yes
• No

If yes, who has access to them and what are the safety protocols around them?

Is there any history past or present of abuse or violence? *

• Yes
• No

If so, please explain:

Are you currently using any illegal drugs, or prescription medications in a way other than was prescribed, or is the reason you are seeking therapy services substance related? *

Have you ever witnessed or experienced a trauma? Do you have reoccurring nightmares, flashbacks, or do you avoid anything that is uncomfortable or painful? If so, please explain: *

Do you have currently legal issues or is the reason you are seeking therapy related to a court order? If so, please explain? *

Career/Job, Recreation and Leisure

What is your current occupation? How would you describe your fulfillment of your job/career? *

What is your highest level of education completed and field of study? *

What do you enjoy doing during your free/leisure time? *

Intimate Relationships

If you are currently in a relationship, describe your relationship: *

How would you describe your communication? *

How would you describe intimacy in your relationship? *

* If you are in a relationship answer the following regarding your relationship:

Like *

Dislike *

Not enough of *

Too much of *

Ideal relationship *

Understanding Your Family & Influences

Please describe your relationship with your parents: *

How would you describe your upbringing? *

Who lives with you currently? *

Do you have any pets? If yes, names, types and relationship to each pet: *

Describe your relationship with the following:

Mother: *

Father: *

Mother’s Significant Other: *

Father’s Significant Other: *

Siblings: Age, Name and Sex: *

Children: *

Significant Other/Spouse: *

Relationships

Describe your relationship with your friends: *

Who would you say your support system is (people, organizations, or affiliations)? *

Do you belong to any religious or spiritual groups? *

• Yes
• No

If yes, what is your level of involvement?

How do your religious or spiritual beliefs/practices influence your life? *

Please list anything else that is important for us to know about you that would assist us in working with you to achieve your desired results: *

Terms of Use *

• Yes, I want to submit this form By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold TJocelyne Counseling and Consulting Clinic LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Submit

425 Pleasant Street

First Floor suite 102

Brockton, MA 02301

Call:  (508) 580-0364

Email: intake@tjocelyne.org

Send Your Question...

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Phone *

Email *

Comment or Message *

Terms of Use *

• Yes, I want to submit this form By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold TJocelyne Counseling and Consulting Clinic LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Submit